Provider Demographics
NPI:1578546040
Name:GROVER, ELLEN R (PT)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:GROVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1811
Mailing Address - Country:US
Mailing Address - Phone:503-287-6636
Mailing Address - Fax:503-287-4044
Practice Address - Street 1:3016 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1811
Practice Address - Country:US
Practice Address - Phone:503-287-6636
Practice Address - Fax:503-287-4044
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2270225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR113611Medicare PIN